Mark Burbridge

Ventriculoperitoneal Shunt Insertion Under Monitored Anesthesia Care in a Patient With Severe Pulmonary Hypertension.

A 32-year-old man with severe pulmonary arterial hypertension and Eisenmenger syndrome secondary to congenital ventricular septal defects presented for ventriculoperitoneal shunt insertion. Consultation between surgical and anesthesia teams acknowledged the extreme risk of performing this case, but given ongoing symptoms related to increased intracranial pressure from a large third ventricle colloid cyst, the case was deemed urgent. After a full discussion with the patient, including an explanation of anesthetic expectations and perioperative risks, the case was performed under monitored anesthesia care. Anesthetic management included high-flow nasal cannula oxygen with capnography and arterial blood pressure monitoring, dexmedetomidine infusion, boluses of midazolam and ketamine, and local anesthetic infiltration of the cranial and abdominal incisions as well as the catheter track. Hemodynamic support was provided with an epinephrine infusion, small vasopressin boluses, and inhaled nitric oxide. The patient recovered without any significant problems and was discharged home on postoperative day 3.

Awake craniotomy in a developmentally delayed blind man with cognitive deficits

PurposeTo describe the complex perioperative considerations and anesthetic management of a cognitively delayed blind adult male who underwent awake craniotomy to remove a left anterior temporal lobe epileptic focus.Clinical featuresA 28-yr-old left-handed blind cognitively delayed man was scheduled for awake craniotomy to resect a left anterior temporal lobe epileptic focus due to intractable epilepsy despite multiple medications. His medical history was also significant for retinopathy of prematurity that rendered him legally blind in both eyes and an intracerebral hemorrhage shortly after birth that resulted in a chronic brain injury and developmental delay. His cognitive capacity was comparable with that of an eight year old. Since patient cooperation was the primary concern during the awake electrocorticography phase of surgery, careful assessment of the patient’s ability to tolerate the procedure was undertaken. There was extensive planning between surgeons and anesthesiologists, and a patient-specific pharmacological strategy was devised to facilitate surgery. The operation proceeded without complication, the patient has remained seizure-free since the procedure, and his quality of life has improved dramatically.ConclusionThis case shows that careful patient assessment, effective interdisciplinary communication, and a carefully tailored anesthetic strategy can facilitate an awake craniotomy in a potentially uncooperative adult patient with diminished mental capacity and sensory deficits.RésuméObjectifDécrire la complexité des considérations périopératoires et de la prise en charge de l’anesthésie chez un homme aveugle avec retard de développement subissant une craniotomie éveillée pour retirer un foyer épileptique situé au niveau du lobe temporal antérieur gauche.Éléments cliniquesUn homme de 28 ans, aveugle, gaucher et présentant un retard de développement, devait subir une craniotomie éveillée pour réséquer un foyer épileptique au niveau du lobe temporal antérieur gauche causé par une épilepsie réfractaire malgré de nombreux médicaments. Ses antécédents médicaux étaient également importants en raison d’une rétinopathie de prématurité qui l’avait rendu aveugle des deux yeux d’un point de vue légal ainsi que d’une hémorragie intracérébrale survenue peu après la naissance, laquelle a entraîné une lésion cérébrale chronique et un retard de développement. Ses capacités cognitives étaient comparables à celles d’un enfant de huit ans. Étant donné que la préoccupation principale pendant la phase d’électrocorticographie éveillée de la chirurgie était la coopération du patient, une évaluation minutieuse de sa capacité à tolérer l’intervention a été menée. Les chirurgiens et les anesthésiologistes ont effectué une préparation détaillée, et un dosage de médicaments adapté au patient a été mis au point afin de faciliter la chirurgie. L’opération s’est déroulée sans complication, le patient n’a pas eu de crise depuis l’intervention, et sa qualité de vie s’est considérablement améliorée.ConclusionCe cas démontre qu’une évaluation méticuleuse du patient, une communication interdisciplinaire efficace et une stratégie soigneusement personnalisée pour l’anesthésie peuvent faciliter une craniotomie éveillée chez un patient adulte potentiellement récalcitrant et présentant des capacités mentales amoindries et des troubles sensoriels.

Manuscript a novel use for the precordial Doppler to verify central venous access

use of the precordial Doppler (Versatone, MedaSonics, USA) in verifying the intravenous placement of a central venous catheter. The precordial Doppler is otherwise commonly used during neurosurgical procedures to monitor for venous air embolism. This case involves a 58-year-old morbidly obese female (body mass index = 58) presenting for clipping of a ruptured aneurysm of the middle cerebral artery under mild hypothermia. Preoperatively, a 22-g upper extremity intravenous catheter was placed; however, three attempts were required owing to poor venous targets. After induction of anesthesia, a similar lack of appropriate venous targets was noted even with extensive ultrasound imaging in both upper and lower extremities. A large bore central line sheath (9 French, 10 cm sheath, Arrow International, USA) was therefore indicated. The surgical team required the right side of the neck to be sterile for possible clamping of the internal carotid artery, if aneurysm rupture necessitates gaining proximal control. The subclavian placement of the sheath was also deemed undesirable owing to the patient’s body habitus. A right internal jugular attempt was made by the anesthesia resident, but an inadvertent carotid puncture produced a large hematoma that subsequently obscured the visualization of the internal jugular vein and carotid artery. The decision was then made to gain access to the femoral vein. Under ultrasound imaging, the right femoral vein was cannulated with the aforementioned sheath, and its placement was verified with a central venous pressure (CVP) of 5 cmH2O, a characteristic CVP waveform, and positive aspiration of dark, non-pulsatile blood. However, concern regarding migration of this line from the vein remained during this long procedure owing to the deep location of the vein (7 cm below the surface of the skin) and presence of copious mobile adipose tissue that could possibly shift the line with positioning changes. Increased compliance of the patient’s skin and subcutaneous tissues probably would have made it difficult to detect the line migrating out of the femoral vein otherwise. To monitor the intravenous placement of the line, a precordial Doppler was positioned on the anterior aspect of the chest in the 2nd intercostal space on the right side. Intermittent rapid flushes of 10 ml of saline were administered during the procedure, resulting in the characteristic turbulent acoustic signal, thereby verifying the intravenous placement of the sheath. Just prior to aneurysm clipping, the intravenous placement of the line was again verified to aid in fluid and/or blood transfusion in the event of sudden massive blood loss. The line remained in the desired intravenous location during the procedure, and its position was again verified upon arrival to the intensive care unit post-operatively. The correct placement of central venous lines can be verified by several techniques including radiography, central venous waveform analysis, and ultrasound techniques [1,2]. This novel technique has not been described previously, and can henceforth be considered as an acceptable technique to verify the initial placement and/or continuous placement of central venous lines. Letter to the Editor

Intraoperative Tonic-Clonic Seizure Under General Anesthesia Captured by Electroencephalography: A Case Report

We present the case of a 34-year-old man undergoing craniotomy for arteriovenous malformation resection under general anesthesia who suffered a tonic–clonic seizure captured by intraoperative electroencephalograph. The seizure was extinguished with a propofol bolus. This patient had no previous history of seizures, and no precipitating cause was identified. Intraoperative electroencephalographic seizures under general anesthesia have been recorded previously in the literature, but our observation is the first to demonstrate this with overt motor manifestations. We also discuss the differential diagnosis of an intraoperative seizure under general anesthesia and provide guidance to the anesthesiologist who encounters this event.

Dermographism: A Rare Cause of Intraoperative Hypotension and Urticaria.

A 54-year-old man with dermographism presented for spine surgery, and shortly after induction of anesthesia, he experienced severe hypotension and urticaria, resulting in cancellation of the case on suspicion of allergic reaction. For subsequent ventral hernia repair, a perioperative management strategy was devised, which resulted in an uneventful perioperative course. This case report is the first to demonstrate severe intraoperative hypotension and urticaria from dermographism. We discuss the strategy that made the subsequent surgery a success and provide guidance for practitioners who face a patient with a severe form of this chronic disease.